A 62-year-old female is being evaluated for vague epigastric discomfort which she has had for the past two months. She denies having nausea, vomiting, diarrhea, flank pain or urinary symptoms, but says she might have lost 2-3 pounds during this time. Her past medical history is significant for hypertension. Her daily medications are hydrochlorothiazide and lisinopril. She does not use tobacco or alcohol. Her family history is significant for breast cancer in her mother at age 72. On physical examination, the patient's blood pressure is 133/87 mmHg and heart rate is 73/min. Her BMI is 22 kg/m². The remainder of the examination is unremarkable. Her laboratory test results are as follows:
CT scan of the abdomen shows a 3.6 cm loculated cystic lesion in the head of the pancreas with some wall calcifications. What is the best next step in the management of this patient?

Question

A 62-year-old female is being evaluated for vague epigastric discomfort which she has had for the past two months. She denies having nausea, vomiting, diarrhea, flank pain or urinary symptoms, but says she might have lost 2-3 pounds during this time. Her past medical history is significant for hypertension. Her daily medications are hydrochlorothiazide and lisinopril. She does not use tobacco or alcohol. Her family history is significant for breast cancer in her mother at age 72. On physical examination, the patient's blood pressure is 133/87 mmHg and heart rate is 73/min. Her BMI is 22 kg/m². The remainder of the examination is unremarkable. Her laboratory test results are as follows:

CT scan of the abdomen shows a 3.6 cm loculated cystic lesion in the head of the pancreas with some wall calcifications. What is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Cystic lesions in the pancreas are usually found incidentally on abdominal imaging and are classified as pseudocysts, non-neoplastic, or neoplastic. Endoscopic ultrasound (EUS) uses ultrasound guidance of the endoscope for needle biopsy of lesions too small to be identified by CT/MRI or that are encased by vascular structures (making percutaneous biopsy difficult). EUS is most effective for biopsying lymph nodes and lesions in the pancreas, liver, adrenal gland, bile duct, peritoneal fluid, and pleural fluid. (Choice A)ERCP is indicated for evaluation of pathology in the pancreas and biliary tree, and has potential complications including pancreatitis, bleeding, perforation, and hemorrhage. Safer diagnostic modalities such as EUS are more sensitive than ERCP in evaluating pancreatic lesions. ERCP has evolved into a therapeutic procedure for choledocholithiasis, dilated common bile duct, cholangitis, and acute biliary pancreatitis. (Choice C) Serum carcinoembryonic antigen (CEA) elevation may suggest a mucinous pancreatic neoplasm but there is no direct correlation of serum CEA concentration with malignancy. A high fluid CEA concentration from a cystic lesion is also suggestive of a neoplasm. (Choice D) Pancreatic cystic neoplasms account for nearly 50% of pancreatic cysts and can be asymptomatic. Further analysis with biopsy is required to identify malignant potential. Serial CT scans in 3-6 months are used to monitor benign lesions. (Choice E) Surgery is the primary treatment for malignant lesions in the pancreas. Distal pancreatectomy is done for lesions in the tail and body of the pancreas, whereas pancreaticoduodenectomy is indicated for lesions in the head of the pancreas. Educational objective: Endoscopic ultrasound with aspiration is the best test to evaluate a pancreatic cyst to differentiate malignancy from nonmalignant causes. References: ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts (http://www.ncbi.nlm.nih.gov/pubmed/17764489)

A 62-Year-Old Female Is Being Evaluated for Vague Epigastric Discomfort